PLACE LABEL HERE

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

1.Diagnosis Admit asInpatient ______(reason for admission)

& Status: Place in Observation ______(reason for observation)

2.Unit:  ICU  IMCU/PCU  Telemetry Floor  Any Floor Telemetry  Any Floor (No Telemetry)

  1. Diagnostics:CBC Chem 7 CMP TPN profile

 Theophylline level

PT/PTT

 Serum hCG, for females 10-60 years of age, if no pregnancy test done in the ED

ABG on:Room air O2

Chest X-ray, PA/lateral on admission

EKG

  1. OSA screen: If positive for suspected orreported sleep apnea, initiate Sleep Apnea Orders (form#21266)
  2. VS q 4 hrs ORq ______hrs
  3. Finger stick blood glucosebefore meals and HS for 48 hrs. Notify physician if BG is 180 in 24 hrs
  4. DVT prophylaxis:Foot compression device Sequential compression device (SCD)
  5. Diet: Regular Other: ______
  6. Activity: Bedrest Bathroom privileges Up ad lib Other:______
  7. Nutrition Supplement Orders (form #31417), initiate if patient meets criteria
  8. Nutritional consult: Reason: ______
  9. Diabetes Education consult: Steroid induced hyperglycemia Other:______
  10.  Foley catheter. Remove Foley catheter per protocol (policy #6143)

 Foley catheter. Do not remove Foley catheter until ordered

14.Urinary Retention Orders (form #31620), initiate if patient has urinary retention or difficulty voiding

RESPIRATORY CARE

15. O2 per Respiratory Care Protocol (# 7504-10-01-03)

16. Respiratory Evaluate and Treat Protocol (# 7504-10-07-01)OR ______

17. Metered Dose Inhalers (MDI):

Combivent (albuterol/ipratropium):______puffs q ______hrs

Advair (salmeterol/fluticasone) HFA 2 puffs q 12 hrs: 45/21 115/21 230/21

Spiriva (tiotropium)1 capsule inhalation q 24 hrs. D/C this order if Atrovent (iptatropium) or Combivent (albuterol/ipratropium)is ordered

Flovent (fluticasone) q 12 hrs: 220 mcg ____ puffs 110 mcg ____ puffs 44 mcg___ puffs

Other: ______

18. Aerosol treatment:Albuterol 2.5 mg q 4 hrs while awake and prn

Albuterol 2.5 mg q 4 hrs and prn

Atrovent (iptatropium) 0.5 mg q 4 hrs while awake

Atrovent(iptatropium) 0.5 mg q 4 hrs

Other: ______

19. Sputum collection per Respiratory Care Policy(# 7504-03-02-20)for culture and gram stain

20. Pulmonary Rehabilitation Evaluation

21. Consult Respiratory Care for smoking cessation program if patient is a smoker

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

22.  INT  IVF ______IV at ______ml/hr

23. Antibiotics if indicated:

 Zithromax (azithromycin) 500 mg po x 1 dose, then 250 mg q 24 hrs

 Ceftin(cefuroxime) 500 mg po q 12 hrs

Doxycycline100 mg po BID

Bactrim DS(trimethoprim/sulfamethoxazole) 1 tablet po BID

Amoxicillin 500 mg po TID

 Avelox(moxifloxacin) 400mg po daily(not recommended if patient has received any fluoroquinolone in the past 30 days)

24. Steroids:Solu-Medrol (methylprednisolone) ______mg IV q ______hrs

Prednisone ______mg po q______hrs

25. DVT prophylaxis:Heparin 5,000 units SQq 8 hrs

 Lovenox (enoxaparin) 40 mg SQ q 24 hrs (if CrCl < 30, 30 mg SQ daily)

26. Stress ulcer prophylaxis:Pepcid(famotidine) 20 mgpo twice daily

OR Proton Pump Inhibitor Oral: Prilosec (omeprazole) 40 mg po daily

 IV: Protonix (pantoprazole) 40 mg IV daily

27. Nicotine patch 14 mg apply dailyNicotine patch 21 mg apply daily

28. Pneumococcal vaccine 0.5ml IM x 1 tomorrow at 2100

29. Influenza vaccine 0.5ml IM x 1 tomorrow at 2100 in season (Oct-Mar)

PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)

30. Adult Electrolyte Replacement Orders (form # 21340), initiate

31. Mild pain/temp>100.5F/HA: Tylenol (acetaminophen) 650 mg po q 4 hrs prn

32. Nausea/Vomiting:Zofran (ondansetron) 4 mg po or IV q 6 hrs prn

Reglan (metoclopramide) 10 mg po or IV q 6 hrs prn (5 mg if 65 y/o)

Phenergan (promethazine) 12.5-25 mg po or per rectum q 4 hrs prn

33. Sleep: Ambien (zolpidem) 5-10mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs

If > 65 year old, begin with 5 mg po at HS, may repeat x 1 dose after 2 hrs

Other:______

34. Indigestion: Maalox XS (aluminum/magnesium/simethicone)30 ml po four times daily prn

35. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement

36. Constipation (if no BM in 48 hrs): Dulcolax (biscodyl) 10 mg per rectum x 1 dose

 Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

37. Cough: Robitussin (guaifenesin) 15 ml po q 4 hrs prn

If cough unrelieved by guaifenesin, Hycodan (HYDROcodone/homatropine) 5 ml po q 4 hrs prn

38. Sore Throat: Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:______

______

______

DateTimePhysician SignaturePID Number

Send copy to pharmacy

FORM 3-16573 REV. 07/2012 Page 2 of 2